In Swaziland, Science Revives an Old RiteCircumcision Makes a Comeback to Fight AIDS in Virus-Ravaged African
Nation

By Craig Timberg
Washington Post Foreign Service

MBABANE, Swaziland -- For 150 years, Swazi men such as Howard
Mlondolozi Dlamini honored the wishes of a long-dead king who,
fearing for the readiness of his young troops, banned the
time-consuming rituals of circumcision that mark the arrival of
adulthood throughout much of Africa.

Today, the biggest threat to Swaziland is not invasion but AIDS, and
a study in neighboring South Africa has revealed that male
circumcision decreases the likelihood of contracting the disease. As
news spreads, the surgery has made a sudden comeback in a country
that has among the world's lowest rates of circumcision and the
highest rates of HIV infection.

In recent months, hundreds of Swazi men have been circumcised.
Dlamini, 42, ... underwent
a 30-minute procedure in September.

"I have seen people dying left and right, and leaving children," said the
hospital administrator and father of two, who has lost three close
relatives to AIDS. Speaking in the nearby city of Manzini, he recalled
thinking, "To take good care of my children, let me undergo the
procedure." [Clearly, his thinking was magical. At 42, he might more rationally have thought, "...let me practise safe sex" or "...let me be faithful to my wife, and she to me."]

... Since the South African report appeared saying
that circumcised men are 60 percent less likely to contract HIV, the
shift in Swazi attitudes toward circumcision -- once widely viewed as
unmanly -- has been dramatic and swift.

Hospitals that once rarely performed circumcisions have recently been
doing 10 to 15 a week, with two-month waiting lists.

...

Although some international donors have warned that the study is not
definitive, and some critics in the United States and elsewhere
regard male circumcision as a form of mutilation, many Swazi men, and in
some cases women, are taking action.

After learning of the research, Lungile Maziya, 35, a pharmacy
technician, scheduled circumcisions for all four of her sons, ages 6
to 15. She also scheduled the surgery for her husband, a practical
precaution in a nation where polygamy is still practiced and wives in
monogamous marriages rarely count on faithfulness from their spouses.

Only her 15-year-old balked. She said she told him, "My boy, when
you're 18, you'll really thank me for this."

Ritual circumcision once was routinely practiced across sub-Saharan
Africa as boys reached puberty. But it has become far less common,
especially in southern Africa, as traditional values have slipped
away and young Africans have moved to densely packed urban areas.

The South African study was the first to experimentally test the
effectiveness of circumcision in preventing HIV, but dozens of
studies have shown that infection rates are far higher in regions
with low circumcision rates. [This is a wild exaggeration: several studies, poorly controlled for confounding factors, have found that infection rates are somewhat higher...]

In Kenya, the national infection rate is 7 percent, but among the Luo
tribe, which does not traditionally circumcise boys, it is 24 percent.
Overall, no country that circumcises a majority of its boys has an HIV
rate among working-aged adults higher than 7 percent.

The South African experiment recruited 3,274 young men in Orange Farm
township and performed the surgery on half. After 18 months, 49 of the
uncircumcised group had become infected with HIV, but only 20 who had been
circumcised were infected. The team of French and South African
researchers calculated that the circumcised men were 60 percent less
likely to get HIV.

The study has been attacked by opponents of circumcision in the
United States and Europe, who regard it as akin to female genital
mutilation, still common in some traditional societies but widely
condemned elsewhere.

There are other drawbacks. In the first several weeks after the
surgery, men are actually more vulnerable to HIV because the virus
can easily enter the wound. Even some advocates of circumcision worry that
newly circumcised men may wrongly believe they are totally protected and
engage in more high-risk sexual behavior.

The South African study, in fact, found an increase in the number of
sexual partners among the circumcised men, though even with their
riskier behavior, they still contracted HIV far [somewhat] less frequently than those who were not circumcised.

The largest international supporters of AIDS prevention have treated
the results cautiously, saying they must wait for results from
similar experiments in Uganda and Kenya before deciding whether to
offer circumcision far more widely in countries with high rates of
HIV.

"They are waiting for a vaccine," Bertrand Auvert, the lead
researcher, said from Paris. "They are not waiting for a cut from
some scissors."

But two prominent Americans based in the capital have aggressively
pushed news of the circumcision research into the public
consciousness here. Daniel Halperin, a researcher and AIDS technical
adviser for the U.S. Agency for International Development, has
convened meetings among Swazi doctors to discuss the research.

Alan Brody, the top official in Swaziland for UNICEF, began
incorporating messages about the protective effects of circumcision
in public education campaigns in 2002. With the results from South
Africa, Brody has become increasingly vocal. Now, official
discussions are focusing not on whether to make circumcision more
widely available, but how.

Swaziland's health system is already overwhelmed with cases of
late-stage AIDS and a rapidly expanding program of antiretroviral
drugs. The country has just eight surgeons and about 50 practicing
doctors. Nurses also are in short supply, and newly trained medical
personnel frequently leave for better pay and conditions abroad.

But those who remain fear that if the medical system doesn't keep up
with the demand for circumcision, the surgery increasingly will be
done in unhygienic, ritual settings or hastily established operating
rooms. Brody has suggested using the military to set up mobile
hospitals that would move from village to village, offering free
circumcisions to any male between 10 and 24. Under that scenario,
nurses or paramedics would be trained to perform the surgery, which
is relatively uncomplicated. Yet even he acknowledges that such an
approach would require some 150,000 circumcisions and could take two
years.

"This is a crisis," Brody said. "The science is in place to say,
'Let's move forward,' at least in Swaziland and also in most of
southern Africa. Let's not delay."

Marwick T. Khumalo, a legislator who credits circumcision with
protecting him from HIV [On what basis?], has put his advocacy in explicitly Swazi
terms, telling parents that their paternal bloodline depends on
protecting their sons from the virus.

"It's important that people preserve their family legacy, their
family name," Khumalo said in the nearby town of Ezulwini.

In Mbabane, Themba Ntiwane, a physician with a weekly call-in radio
show, first spoke of circumcision in September. The board soon lit
up, and the calls have not stopped.

"Everyone wants to have it done," Ntiwane said. "Not one person has
called to say it's 'un-Swazi.' "

Vincent Bartoo
Nairobi
As the country grapples with the deeply rooted Female Genital Mutilation
(FGM), efforts being applied to eradicate the vice are now being
replicated to phase out traditional circumcision among boys. [No, they are capitulating to "the vice".]

And the Church, which in recent years faced a lot of opposition from most
communities in Kenya when it introduced an alternative rite of passage for
boys, is slowly, but steadily winning the war.

The churches have aggressively fought this age-old norm, gradually
replacing it with a modern, safe and effective method of initiating boys
into manhood.

From secluding initiates in hospitals after undergoing circumcision, the
churches have now gone full throttle, taking charge of circumcision
ceremonies deep in the bushes and subsequently stealing the thunder from
traditional circumcisers.

Consequently, the notion that only those who have undergone traditional
circumcision are "real men" over those who choose the modern method may
eventually be wiped out. One church that has successfully embraced this
new method , and is winning praise, is the Presbyterian Church of East
Africa.

"Since the year 2001, we have taken close to 4,500 boys through the
alternative rite of passage and the current demand for this programme is
great," said Haggai Nderu, the programme facilitator in Eldoret.

In an interview with The Standard at the church where 59 boys are
undergoing the rite, Nderu said their war, in stemming the now dangerous
traditional methods of circumcision, was unstoppable.

"I call them dangerous because through them, the deadly HIV/Aids virus can
easily be passed onto our children right under our noses. Who will take
the blame for it if not us," he said.

Stemming the tideNderu added: "There is also evidence that the traditional methods have
transformed boys into chauvinists, young men who will not take
instructions from their parents or seniors and instead opt for their own
way of living, ending up in self destruction".

...

A year or two later saw many other Eldoret residents, even choosing to
circumcise their children through the church. The Kalenjin are among
communities in Kenya that still practice and uphold traditional
circumcision for both boys and girls.

"It has become routine now. When December approaches, parents come to
church to register their children for circumcision and we do not
discriminate. Anyone can bring his child to us," Nderu said.

...

"We first counsel them about what they are about to go through before a
qualified doctor performs the circumcision," said Nderu.

...

When The Standard visited the current group of initiates, they were busy
learning the connection between the Biblical way of circumcision and the
current practice.
[...but not, presumably, that circumcision has no value for Christians.]

Save for the wraps around their waists, the boys would easily pass for
students attending tuition or attending a seminar.

And unlike the traditional rites where initiates spend up to a month in
the bush under harsh conditions, initiates in the new method are ready to
"graduate" after two weeks when relatives and friends throng the church
for celebration.

The Government, through the Provincial Administration, is among those
hailing the circumcision method as "the most appropriate one in this era
of HIV/Aids ".

Circumcision in the MediaRebecca Goldin
A one-sided account of a debatable medical procedure

The L.A. Times just got tough about circumcision. They cite a new study,
published in Public Library of Science Medicine, showing that circumcised
boys [No, men] are less like to get the HIV virus than uncircumcised boys. From
this, the L.A. Times leaps to the conclusion that all boys should be
circumcised. As they put it, "Circumcision may protect against HIV
infection, new studies suggest. But more parents are forgoing the
surgery." While lauding the benefits of circumcision and lamenting the
declining circumcision rates in the United States, the Times is diverging
from advice given by the American Academy of Pediatrics (APP). The APP
currently maintains that there is no medical reason for all boys to
undergo the procedure. And it is not changing its position because of this
new HIV study.

The study was conducted in South Africa, where infection rates for HIV are
high and increasing. Two groups of boys were randomly assigned to undergo,
or not, circumcision. Those boys who underwent the surgery were less than
half as likely to get the HIV virus. Such strong numbers are extremely
important, and highly suggestive that, in an environment in which HIV
infections are common, circumcision could play a preventative role.

So why didn't the AAP change its tune? Doesn't preventative medicine
clearly dictate that all boys - and even adults who are still clinging to
their foreskin - be circumcised as a matter of routine? Clearly, this is
the suggestion given by the L.A. Times in quoting Robert Bailey, a lead
author of the study "One of the benefits [circumcision] has is that it is
permanent and protects every time." [The second part is false and dangerous.]

The reason that doctors haven't jumped is buried in the numbers. Numbers
that the L.A. times didn't bother to write about.

The actual likelihood of
any individual getting HIV in the United States is extremely low. The L.A.
Times cites the statistic that there are 40,000 new HIV cases a year in
the United States. However, they do not break that up into the categories
of infection that might be affected by circumcision.

The new infection
rate includes babies [who] get HIV from their mothers and teens [who] get infections
through sharing needles. Based on information published by the Center for
Disease Control, STATS estimates that the number of new male infections
due to unprotected sex is about 21,000 per year. And if we assume that the
rate is halved if the men were circumcised (a conservative assumption,
since many of the new infections are already circumcised men), we reduce
new infections by about 11,000 per year by circumcising every male baby in
the country. And there are more than 2,000,000 new baby boys born in the
United States each year. That's a lot of circumcisions for the benefit - a
reduction of 5.5 HIV infections per 10,000 circumcisions.

While it is true that there are decreased rates of urinary tract
infections, penile cancer, HIV, and some sexual transmitted diseases among
circumcised boys and adults [actually all of these claims are also debatable], all of these problems occur in an extremely
small percentage of the population. Condoms and reduced exposure to others
with the virus minimize the chance, while drug use and unprotected sex
increase the risk.

The L.A. Times' recommendation would fare better in
populations with high risk. This may include some cities and some
subpopulations in the U.S., but does not mean the whole country. The
current rate of HIV (not AIDS) infection in the United States is estimated
at 136.7 per 100,000 people (CDC, 2004), or just over 1 person per 1,000,

With a lifelong-risk of under 0.15%, Americans are justified in making
their decisions about circumcision independent of the possibility of HIV
infection [assuming it is ethically justifiable to make a decision about the ownership of another person's body part at all]. Quite reasonably, parents who are reluctant to expose their
children to the known risks of circumcision (most notably, infection,
pain, scarring, and bleeding [which may cause death]) may not feel that the reduced HIV risk is
worth it.

Transcript of an interview with Dr Michael Wilkes, chair of the British Medical Association's medical ethics committee, part of an item on circumcision and foreskin restoration in the ‘Outlook’ programme:
Interviewer: I’m here at the British Medical Association to ask Dr. Michael Wilkes about circumcision and, in
particular, whether it’s true that unnecessary circumcisions are being carried out.

Dr. Wilkes: There is hardly a reason to circumcise a little boy for medical reasons, because those medical reasons don’t exist. We do accept as a, by definition of medical reasons and benefit medically that comes from that, that the Jewish faith have a strong tradition and therefore a strong claim to continue this practice.

Interviewer: Medically, what reason would there be to circumcise either a youngster or an older person?

Dr. Wilkes: The vast majority of cases, for instance of non retractile foreskin, which is a developmental thing, It just takes time, sometimes, for the tissue between the foreskin and the glans of the penis, the sensitive part of the penis [wrong], to break down so the foreskin can be put back [retracted]. It’s often a question either of time or of very gentle manipulation, certainly not surgery.

Interviewer: So the people of NORM UK that feel that as if they’ve been circumcised for the wrong reasons -
in the past, do you think doctors have circumcised for no good reason maybe?

Dr. Wilkes: Yes I do, I do, and I suspect that some people from NORM UK, those who are not members of the strong Jewish tradition, for instance, or maybe slightly less persuasive that - certainly in Muslim tradition - the majority of people who have been circumcised in the past for what was put to them, or put to their parents, as good medical reasons, were probably no such thing, and those people certainly have a right to make a claim that what was done to them was an unnecessary and premature intervention, at a time when they had no capacity or say in the matter.

[So men who resent the fact that they were circumcised in infancy have a right to complain about the injustice of the unnecessary medical intervention - unless they're Jewish ... ?]

"Community-acquired methicillin-resistant staph aureus is a substantial
and increasing proportion of staph infection in previously healthy
neonates," Regine M. Fortunov, M.D., of Texas Children's Hospital in
Houston. "Individuals who are most at risk are seven to twelve days of
age, and male."

MRSA infections in infants who have not been hospitalized except at birth,
and who have had not had surgery other than circumcision, could be due to concurrent infection of mother and child, Dr. Fortunov said at the
American Academy of Pediatrics meeting.

...

They drew from data on a prospective cohort of all children treated at
Texas Children's hospital for S. aureus infections between the summer of
2001 and the spring of 2005. The cases were classified by route of
acquisition, either nosocomial [in-hospital] or community acquired.

They looked at the demographics, hospital course and outcome of a subgroup
of patients who were younger than 30 days old when they were diagnosed
with community-acquired MRSA. The babies, all of whom were full-term or
near-term neonates (> 36 weeks gestation) had been healthy before being
infected with community acquired S. aureus. They defined as previously
healthy any child who had no hospitalizations other than at birth, and no
surgery other than circumcision.

They identified a total of 61 cases of MRSA, and 28 cases of
methicillin-susceptible S. aureus (MSSA).

"We saw an increase in the total number of infections each year,
especially 2004," Dr. Fortunov said. "This increase was entirely due to an
absolute increase in the number of MRSA infections

The proportion of infections caused by methicillin-resistant strains rose
from 50% in 2001, to 83% in 2005.

When the authors compared the demographic characteristics of the infants
in the MRSA and MSSA groups, they found no differences in mean birth
weight, gender, caesarean section rate, hospital days at birth, exposure
to antibiotics pre-admission, pets, passive smoking, breast feeding or
circumcision.

[NB: That's no difference between the MRSA and MSSA groups, not no differnce between either group and uninfected babies.]

...

"We did, however, find a significant difference in onset of symptoms," Dr.
Fortunov said. "MRSA infection peaked at seven to 12 days of age, with 51%
of infections occurring during this time; we observed no peak in MSSA
disease. Additionally, this peak was only observed in male infants."

Although both MRSA and MSSA occurred predominantly in boys -- about 73% in
each group -- after further analysis the investigators observed an
infection peak only in boys infected with MRSA.

In both groups, putulosis in the groin, upper thigh, and sacral area -
areas covered by diapers - was a common presentation. Both groups had
invasive infections, including shock, musculoskeletal infections, urinary
tract infection, perinephric abscess, bacteremia, and empyema. There was
one death, in a child with MRSA.

"Interestingly 10 of the 12 invasive infections, including the death, occurred in male infants," Dr. Fortunov said. She and colleagues had no explanation for this. [Well, duh]

Another surprising finding, she said, was that 12 of 89 mothers had a skin
infection at the time of the babies' presentation.

Newborn babies feel more pain than adults but it is often undertreated by doctors, a pediatrician says.

Releasing Australian guidelines for doctors managing pain in children, Angela Mackenzie said the part of the nervous system that could turn down pain was under-developed in babies, making them highly sensitive to medical procedures.

"We used to think that neonates didn't feel pain," said Dr Mackenzie, chair of a Royal Australasian College of Physicians working group which developed the guidelines.

"Because their nervous systems are immature, we thought that meant they were unable to experience pain and up until about 30 years ago, we were operating without giving them good analgesia.

"Actually, babies feel more pain than adults and we're just catching up with that."

If not adequately treated, Dr Mackenzie said pain could have long-term consequences for children, altering nervous system development and ultimately making them even more sensitive to pain. ...

Children having to undergo regular procedures were at particular risk unless their pain was addressed. And not just with drugs.

"If you've got a chronic illness and you need lots and lots of procedures, if the pain isn't dealt with, if you're not taught ways of how to cope with it, you actually feel more pain as you have more procedures," Dr Mackenzie explained in an interview.

"Our thoughts and our feelings contribute to pain. Pain's not a given. It's not like you have this needle and you get a specific amount of pain.

"In the same way as we can ignore pain, if we're anxious about it, it makes the pain worse. There's this pain anxiety spiral.

"I've worked with children who feel pain and no-one's gone near them. It's like the memory is in there. Once you've got that in place, there's no quick fix. It's harder to treat."

The guidelines included information about the importance of trying to distract children from painful procedures such as talking about their favourite things, blowing bubbles or reading aloud.

Even newborns could benefit from a multi-sensory approach to reducing pain such as a mother wearing the same perfume around the baby, reducing lights and noise in neonatal units, breastfeeding and touch.

The guidelines, launched in Sydney on the Global Day Against Pain, included a 24-page section on treating pain in newborns and 69 pages covering children and adolescents.

Dr Mackenzie, based at the Royal Children's Hospital in Melbourne, said the guidelines recommended against health professionals fast-tracking medical procedures in children "to get it over with".

"We used to think `we've got to get this blood, let's just get it, focus on the procedure and what we need to do'," she said.

"That, of course, doesn't take into account the child. We didn't think pain was such a problem in children. We thought children would get over pain, or they perhaps didn't feel it as much, or they'd forget about it.

"We didn't understand the long-term consequences of untreated pain or undertreated pain, one of which is children becoming adults who are frightened of medical procedures and avoiding them.

"In the short-term too, children become depressed and irritable."

In severe cases, Dr Mackenzie said some children - and even their parents - developed post-traumatic stress disorder.

"This has been described in mothers of children with leukaemia," she said.

Neonatologist David Henderson-Smart, of the University of Sydney, received a two-year grant worth $200,000 to implement the new guidelines in newborns across Australia and New Zealand.

A renowned expert on sexually transmitted disease denounced as “outrageous” this week the Bloomberg administration’s failure to ban New York City mohels from suctioning blood with their mouths from a baby’s penis in the circumcision rite.

“[It] is a major public health hazard,” declared Dr. Jonathan Zenilman, a professor of epidemiology at the Bloomberg School of Public Health — the Johns Hopkins University education and research center named for New York’s philanthropist mayor, its biggest financial supporter.

Zenilman, who grew up in an Orthodox family in Woodmere, L.I., warned that allowing the practice known as metzitzah b’peh “is actually crazy” due to the potentially fatal danger of transmitting herpes to vulnerable newborns.

A prominent colleague, Dr. John Santelli, chair of the Department of Population and Family Health at Columbia University’s Mailman School of Public Health, joined the criticism.

“Those kids are at very high risk of death and encephalitis,” he said, explaining, “If you cut the skin — as obviously you have to in a circumcision — it increases risk of transmission to the infant. Newborns just don’t have great immune systems, so the worst time to get a case of herpes is in the newborn.”

Metzitzah b’peh, which is practiced routinely by some fervently Orthodox mohels, has been at the center of a case involving Rabbi Yitzchok Fischer, a Monsey-based mohel suspected of having infected three babies with herpes. One of the baby boys died last October.
...

A 31-year-old Nigerian man has been found not-guilty of reckless endangerment in relation to a circumcision that resulted in the death of a four-week-old baby boy in Waterford city two years ago.

Mr Osagie Igbinedion was found not guilty by a jury of 10 men and two women at Waterford Circuit Court this afternoon.

He was accused of intentionally or recklessly engaging in conduct, by performing a circumcision with a razor blade, which created a substantial risk of death or serious harm to 30-day-old Callis Osaghie.

Judge Kevin Haugh, directed the jury saying that they could not bring their white western values to bear when they were deciding this case.